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'They have charge of 600 young people, therefore it is essential that they have sufficient policies.'

Jack was prescribed Roaccutane by Dr
James Milne at the Nuffield Health centre in Cheltenham, after being
referred to the skin specialist by his GP, in December 2011.

Dr Milne prescribed an initial dose of two capsules, which was increased up to three capsules on January 20 2012.

Within three days, Jack told matron Tracey Hopson that he was experiencing 'very dark thoughts' and considering suicide.

He was taken back home to Wantage in
Oxfordshire, by parents Michael and Mandy Bowlby, and his dose of
Roaccutane was reduced to one capsule daily.

Dr Milne had advised Jack and Mrs
Hopson, who attended medical appointments with the boarder, that he
should be informed immediately if any side effects were experienced.

But Mrs Hopson did not contact Dr
Milne and the incident was not entered in Jack’s medical notes at
Cheltenham College. He returned to the school three days later and
appeared 'back to normal', according to staff.

Dr Milne previously told the inquest
that if he had been informed of the development, he would have
immediately stopped Jack’s treatment and referred him to a psychiatrist.

Prestigious: The talented teenage horse rider, and nephew of former champion racehorse trainer Jenny Pitman, was a pupil at Cheltenham College

Jack chose not to take Roaccutance
during the summer holidays of 2012 but told Mrs Hopson that he wanted to
restart treatment in October.

Cheltenham College medical records show Jack took a one capsule dose at 1pm on October 11, the day before he was found dead.

Dr Graham Mould, a consultant
pharmaceutical forensic toxicologist, said Swedish research appeared to
show the risk of side effects from Roaccutane peaked within six months
of finishing treatment.

Jack would have been four months into the six-month period at the time of his death.

Dr Mould said: 'I would suggest that
it is possible that Roaccutane was an issue in Jack’s death but I am
unable to say how significant an issue.

'I have to ask myself if he had not
taken Roaccutane over the last six months, would he have taken his life.
I suppose I have to say that probably not.'

Patients taking Roaccutane should be monitored closely through their treatment and for a year after it, Dr Mould said.

Statistics suggest there is a one in 10,000 risk of developing suicidal ideation while taking Roaccutane.

Jack’s father Michael Bowlby said he
and wife Mandy had not been aware the 'dark thoughts' their son
experienced in January included suicide.

Mr Bowlby said: 'That’s something I
was appalled to hear yesterday, that was the first time I heard any
mention of suicidal thoughts in Jack.'

He confirmed that the family had not
sought psychological help for their son or thought to contact Dr Milne
about the side effects, as they had spoken to Cheltenham College.

'Our take on the school is that they
are in their care and if there’s anything going wrong, you would hope
that they would follow it up with us,' Mr Bowlby said.

Mr Bowlby said Jack acted out of
character on a number occasions and told his mother: 'I think it’s these
pills, they make you depressed'.

He contacted Jack’s housemaster, Simon
Cooper, about the change in his son’s mood and character but Mr Cooper
did not seem to grasp the situation, the inquest was told.

Talented: The teenage horse rider was the nephew of Jenny Pitman, who trained Grand National and Cheltenham Gold Cup winners during her career

Ms Karen Davies, deputy head of
pastoral care at Cheltenham College, said: 'One of the problems that
independent schools face is there is some evidence to suggest that
talking and overtly addressing the issue of suicide in young people may
contribute to their problems.'

Recording an open verdict, Mr Osbourne said he could not be sure that Jack intended to take his own life.

He said: 'Jack was a hugely popular,
hard-working young man and in addition, a very talented horseman who
probably had, as everybody perceived, a glittering career in front of
him.

'Sadly that is no longer the case.

'It may have been an accident, it may have been suicide, it may have been Roaccutane. There is insufficient evidence.'

Mr Osbourne recorded that Jack died as a result of neck compression by a ligature.

Speaking after the inquest, Jack’s
family criticised the way Cheltenham College staff dealt with their
son’s 'dark thoughts' episode.

Simon Medland QC, speaking on behalf
of Jack’s mother Mandy, father Michael and brother Thomas, said: 'Our
only hope is that out of this tragedy some good may come.

'We hope that all schools will take
very seriously any such reports and, on occasion, when a child reports
such dark thoughts as Jack did to his house master at Cheltenham, will
follow up such reports in detail.

'In this case no detailed notes were
made on exactly what Jack said about the effects of Roaccutane and
mental instability. And the report which he did make was not formally
transmitted in detail to his doctor, no entry was made in Jack’s school
medical records at Cheltenham College, thus Jack’s dermatologist was not
informed.

'If he had been informed by the
college, he would have told Jack to stop taking the drug and seek help.
If that had happened the outcome, in our view, may have been very
different.

'We feel that Roacutane may have
played a part in Jack’s death and we hope that the rare but serious
side-effects of the drug can be better understood and its prescription
very carefully monitored.

'Patients who are administered their drug, and their parents, should be very aware of the possible risks.'

In a statement, Dr Alex Peterken,
headmaster of Cheltenham College, said: 'There was, sadly, no way of
knowing that Jack was about to die in the way that he did and, as
today’s inquest verdict has shown, his death came as a bolt from the
blue. He could not have been part of a more supportive and close-knit
school and boarding family.

'Jack’s Roaccutane medication was
prescribed independently of college by a private dermatologist with the
full consent and knowledge of his parents. It was dispensed by his house
matron on this basis and fully in line with national boarding
guidelines.

'In January 2012, concerns over Jack’s
emotional well-being were discussed with the family and his medication
subsequently reduced. At all times, college put Jack’s family at the
heart of decision making about his medication and communicated with them
regularly.

'Following January 2012, Jack’s
behaviour at college gave no further cause for concern and he was making
good academic progress in the new school year. Indeed, in the weeks and
days leading up to his death, he seemed to many staff to be at his
happiest and most confident.

'As you would expect, we have
thoroughly reviewed our provision of care for all pupils and we are
fully reassured that it is consistent with the high standards for which
we are known and confirmed by both Ofsted and the Independent Schools
Inspectorate, who have independently assessed the college’s pastoral
care as outstanding.'

For confidential support on suicide matters call the Samaritans on 08457 909090